Psychosocial treatment of late-life depression with comorbid anxiety

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1 Psychosocial treatment of late-life depression with comorbid anxiety Viviana Wuthrich Centre for Emotional Health Macquarie University, Sydney, Australia

2 Why Comorbidity?

3 Comorbidity is Common Common disorders, typically comorbid across the lifespan (Kessler et al., 1996; Kvaal et al., 2008) Community sample in Netherlands aged yrs comorbid prevalence of major depression and any anxiety disorder was 47% (Beekman et al., 2000) Primary care sample (inpatient and outpatient) 35% of those with MDD reported lifetime history of anxiety disorder, and 23% reported a current anxiety disorder (Lenze et al., 2000)

4 Overlap Overlap in terms of risk factors, phenomenologyand genetic factors (particularly GAD and MDD) (Kendler et al., 2007; Vink et al., 2008; Watson et al., 1995)

5 Worse Outcomes In older adults, associated with worse outcomes than either disorder alone: increased risk of cognitive decline and dementia (DeLuca et al., 2005) increased risk of suicide, disability, more severe depression, more chronic course (Cohen et al., 2009;Lenze et al., 2000) higher health care costs (Almeida et al., 2012; Vasiliadis et al., 2012)

6 Poorer Treatment Response Comorbid anxiety reduces treatment response of: pharmacological treatment for depression (Cohen, et al., 2009) combined pharmacological and psychological approaches (Hegel et al., 2005) group CBT (Gum et al., 2007) Treatment for depression doesn t produce significant reductions in comorbid anxiety symptomatology (Gum, et al., 2007; Serfaty et al., 2009) Treatment for anxiety does improve comorbid depression severity but unclear if there is recovery from comorbid mood disorders (Gorenstein, et al., 2005)

7 Disorder Specific Treatment DEPRESSION: CBT is effective for older adult depression and superior to WL, TAU, other control groups with moderate to large ES d=0.72 (Cuijpers et al., 2006; Karel & Hinrichsen, 2000; Mackin & Arean, 2005; Serfaty et al., 2009) Recent meta-analysis suggests CBT is superior to nonactive controls, but not superior to active controls (Gould et al., 2012)

8 Disorder Specific Tx continued ANXIETY: CBT is effective in older adults and superior to WL, active control for anxiety, although it is likely to be only marginally superior than active control conditions (Gould et al., 2012) Little known about treatment of comorbidity and whether if targeting comorbidity would improve outcomes

9 Psychosocial Treatment for Depression with Anxiety

10 Sallis et al N=24 Aged 60+ (m=71.3, sd=8.7) >12 BDI and >38 STAI Compared Anxiety Tx (relaxation) with Depression Tx (pleasant events & cognitive restructuring) and Control (self-disclosure and reflection) Found all conditions produced improvements on BDI, blood pressure (resting systolic and diastolic) Only the placebo group improved on anxiety (STAI)

11

12 Group CBT to Wait list RCT group CBT versus wait list condition (12 weeks) N= 62, Aged 60 + (range 60-84, M=67.77) Comorbid depression and anxiety (clinical or subclinical) as assessed by semi-structured clinical interview (ADIS) and self-report questionnaires Pre, Post and 3 month follow up Wuthrich & Rapee (2013). Behaviour Research & Therapy.

13 Primary Disorder Severity

14

15 Results Large Effect Sizes (within condition) CBT=1.46 (95%CI: 0.74,2.18), Gains maintained at 3 months Recovery Rates for the sample who met full diagnostic criteria at pre CBT 53% recovery (post) and 67% (3 month) Waitlist 11% recovery

16 RCT 2 Wuthrich et al (Psychol. Medicine) DSM-IV anxiety and unipolar mood disorder (either primary) Random allocation by block to group treatment 11 sessions (over 12 weeks) CBT vs Discussion group Pre, Post and 6 month follow up assessments Treatment Adherence and Treatment Credibility Therapist Alliance, Group Cohesion, Process changes

17 Results 133 randomly allocated (77 CBT, 57 Disc) Age years (M=67.35, SD=5.44), Male = 44% No significant differences on demographics, treatment credibility, therapist alliance, group cohesion

18 Results Mean Disorder Severity CBT Discussion 1 0 Pre Post Follow Up

19

20 Mean Depression/Anxiety

21 Recovery Rates Primary Diagnosis Free CBT Discussion Post* 54% 24% Follow Up 46% 36% * p<.001 Completely Diagnosis Free of all Anx or Mood disorders CBT Discussion Post* 38% 12% Follow Up 35% 27% *p<.05

22 Conclusions Group CBT is superior to discussion group for clinician rated symptoms in particular (faster recovery) Group CBT efficacious for depression with anxiety (on both anxiety and depression) Benefits of CBT are maintained at 6 months

23 Current Directions Target amenable risks for cognitive decline Physical inactivity (21% population attributable risk) Low education/mental stimulation (19.1%) Depression (11.1%) Others include: smoking, diet, alcohol, lack of social stimulation and emerging evidence for anxiety RCT lifestyle intervention vs bibliotherapy (16 week individual face to face) Outcomes changes in risks, cognitive changes up to 3 months (with funding outcomes to 2 years)

24 Thank you!

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